What is a nursing audit?

Nursing audit is a detailed process of evaluating the quality of nursing care through the review of clinical records made by healthcare professionals. It helps healthcare institutions ensure that patients consistently receive quality patient care and allows nurse managers to determine healthcare improvement opportunities.

Importance

The purpose of a nursing audit checklist is to assist the head nurse or manager when conducting an audit on their processes and staff. Ideally, it should reflect the patient safety and quality-measurement approach outlined by the Agency for Healthcare Research and Quality. It also helps nursing heads confirm that patient care matches the institution's standards. Reviewing clinical records this way also surfaces gaps and areas for improvement in records management, worker safety, workplace experience, and patient satisfaction.

What a nursing audit checklist covers

A nursing audit checklist typically covers patient assessments, medication administration records, care planning, and infection control documentation. It should confirm that entries are signed, timestamped, and consistent with what staff report happened at the bedside.

Two methods determine when that review happens:

• Concurrent nursing audit: Conducted while the patient is currently undergoing treatment at the healthcare facility. It involves staff interviews and patient assessment in addition to review of the patient's records.

• Retrospective nursing audit: Conducted after the patient's discharge, where the auditor determines the quality of care based solely on clinical records.

5 steps for conducting a nursing audit

Each hospital can do nursing audits differently, depending on their needs and systems. However, this sequence mirrors the broader audit methodology set out in ISO 19011:2026, the international standard for auditing management systems:

1. Create an audit team composed of senior nurses and other members who will be impartial auditors.

2. Help nursing staff understand the goal of the audit and the benefit to the patients, staff, and the healthcare institution.

3. Determine the audit method needed then run the audit using technology that scores results and helps analyze the data gathered.

4. Review and analyze the data gathered to determine if the patient care being provided is at par with the healthcare institution's standards.

5. Promote best practices and maintain quality patient care by conducting internal audits and addressing gaps found.

Nursing audit sample report

Here is an example of a nursing audit template in use:

Nursing audit checklist sample report | Mitti (by SafetyCulture)